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Sources of funding:
Wellcome Trust and
Hounslow and
Spelthorne Community
and Mental Health
National Health Service
Trust.
For correspondence:
Dr T Sensky, Division of
Neurosciences and
Psychological Medicine,
Imperial College School
of Medicine, West
Middlesex University
Hospital, Isleworth,
Middlesex TW7 6AF,
UK. t.skensky@ic.ac.uk
Cognitive behavioural therapy (CBT) v befriending in drug refractory schizophrenia*
Outcomes at 9 months
>50% improvement in CPRS
total scores
>50% improvement in CPRS
schizophrenia change scores
*CPRS=Comprehensive Psychiatric Rating Scale. Other abbreviations defined in glossary; RBI, NNT, and CI cal-
culated from data in article.
116 Volume 3 October 2000 EBN
Cognitive behavioural therapy improved psychiatric
symptoms in drug refractory schizophrenia
Sensky T, Turkington D, Kingdon D, et al. A randomized controlled trial of cognitive-behavioral therapy for persistent
symptoms in schizophrenia resistant to medication. Arch Gen Psychiatry 2000 Feb;57:165–72.
QUESTION: Is cognitive behavioural therapy (CBT) more effective than a befriending
intervention for reducing psychiatric symptoms in drug refractory schizophrenia?
Design
Randomised (allocation concealed), blinded (outcome
assessors), controlled trial with 9 months of follow up
after treatment.
Setting
5 clinical services in the UK (Newcastle, Cleveland, Dur-
ham, and 2 in west London).
Patients
90 patients who were 16–60 years of age (mean age 39 y,
59% men, 89% white), met ICD-10 research and DSM-IV
criteria for schizophrenia, and had symptoms causing dis-
tress or dysfunction for ≥ 6 months despite adequate
doses of antipsychotic drugs. Follow up was 100% for all
outcomes except for scores on the Scale for Assessment
of Negative Symptoms (SANS), which had 98% follow up.
Intervention
Patients were allocated to CBT (n = 46) or befriending
(n = 44). Both interventions were done by the same expe-
rienced nurses. CBT involved attaining a collaborative
understanding of the development of symptoms and
working towards reducing distress and disability. The pro-
vision of CBT was guided by a manual and regular super-
vision. Befriending involved sessions focused on neutral
topics (ie, hobbies, sports, and current affairs). Sessions
were approximately 45 minutes/week for the first 2
months with reduced frequency for the next 7 months
(mean total of 19 sessions). Patients in both groups were
on antipsychotic medication throughout the study period.
Main outcome measures
Scores on the Comprehensive Psychiatric Rating Scale
(CPRS) (total and schizophrenia change scores), the
Montgomery-Åsberg Depression Rating Scale (MADRS),
and the SANS.
Main results
Analysis was by intention to treat. After treatment,
improvement was similar in each group. At 9 months fol-
low up, patients in the CBT group had greater improve-
ment on all outcomes than did those in the befriending
group. More patients in the CBT group than in the
befriending group had ≥ 50% improvement in CPRS
total scores (p = 0.02); a trend existed toward more
patients in the CBT group than in the befriending group
CBT Befriending RBI (95% CI) NNT (CI)
63% 39% 63% (8 to 157) 5 (3 to 28)
70% 50% 39% (−1 to 102) Not significant
with ≥ 50% improvement in CPRS schizophrenia change
scores (p = 0.06) (table). Groups did not differ for patients
with ≥ 50% improvement in MADRS or SANS scores.
Conclusion
Cognitive behavioural therapy led to greater improve-
ment in psychiatric symptoms at 9 months follow up
than did a non-specific befriending intervention in
patients with drug refractory schizophrenia.
COMMENTARY
A recent Cochrane review on the use of CBT for schizophre-
nia showed promising findings but recommended further
large, methodologically rigorous trials.1 In their well designed
and controlled study, Sensky et al compare the role of CBT
and befriending for drug resistant schizophrenia. Although
both groups showed improvements immediately after treat-
ment, only the CBT group continued to improve after the
treatment ended. Clinical improvements were greater for
CBT than for befriending in all 4 outcome measures at 9
months of follow up. At the beginning of the study, patients
showed no evidence of poorer adherence to medication, and
by the end of the study, the results could not be accounted for
by changes in antipsychotic medication.
Strengths of this study are randomised treatment alloca-
tion, blinded outcome assessors, audiotaped sessions to
ensure that the nurses delivered the assigned intervention,
medication monitoring for all patients, and an adequate
follow up period accounting for all participants. Weaknesses
are possible contamination by therapists conducting both
interventions, insufficient detail about the severity of patient
psychosis, inadequate social profiles (eg, socioeconomic
status) of participants to determine representativeness of
study patients to all those with drug resistant symptoms, and
an absence of measures such as relapse and readmission rates.
The positive findings suggest greater internalised ability
and skill acquisition by patients in the CBT group to control
or cope with their persistent symptoms at follow up, whereas
those in the befriending group lost their initial gains once
direct contact with the therapist ended. Given that up to 50%
of patients with schizophrenia are non-responsive to antipsy-
chotic agents, effective psychological interventions, such as
CBT, are viable alternatives or adjuncts to medication. The
cost of specialised CBT training has not been accounted for in
this investigation and is recommended for future research. It
appears that CBT by trained and experienced therapists is
effective for patients who are drug resistant and who do not
experience severe symptoms that would interfere with the
requirements of this intervention. Future research should
more clearly describe those patients who may benefit.
Jeannette LeGris, RN, MHSc
Clinical Nurse Specialist, Psychiatry
Assistant Professor, School of Nursing
McMaster University
Hamilton, Ontario, Canada
1 Jones C, Cormac I, Mota J, et al. Cognitive behaviour therapy
for schizophrenia (Cochrane Review, latest version 28 Jan
2000). In: Cochrane Library. Oxford: Update Software.
Treatment
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Cognitive behavioural therapy improved

psychiatric symptoms in drug refractory
schizophrenia
BMJ Publishing Group Ltd and RCN Publishing Company Ltd

Evid Based Nurs 2000 3: 116

doi: 10.1136/ebn.3.4.116

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